HEMATURIA BASIC COURSE OF DIAGNOSIS

1
HEMATURIABASIC COURSE OF DIAGNOSIS

• Xiaoqi Xu
• Renji Hospital
• Shanghai Second Medical University

2
CONTENT

• Definition of hematuria
• Etiology
• Clinical feature
• Differential diagnosis
• Laboratory tests
• Accompanied symptoms

3
DEFINITION

• More than three red blood cells are found in
• centrifuged urine per high-power field microscopy
• ( gt 3 RBC/HP).
• Normal urine
• no red blood cell or less than three red blood
  cell

4
According to the amount of RBC in the urine,
hematuria can be classified as

• microscopic hematuria
• normal colour with eyes
• gross hematuria
• tea-colored, cola-colored, pink or
• even red

5
ETIOLOGY

• Diseases of the urinary systemthe most common
  cause
• Vascular
• arteriovenous malformation
• arterial emboli or thrombosis
• arteriovenous fistular
• nutcracker syndrome
• renal vein thrombosis
• loin-pain hematuria syndrom
• cogulation abnormality
• excessive anticogulation

6

• Glomerular
• IgA nehropathy
• thin basement membrane disease (incl.Alport
  syndrome)
• other causes of primary and secondary
  glomerulonephritis
• Interstitial
• allergic interstitial nephritis
• analgesic nephropathy
• renal cystic diseases
• acute pyelonephritis
• tuberculosis
• renal allograft rejection

7

• Uroepithelium
• malignancy
• vigorous excise
• trauma
• papillary necrosis
• cystitis/urethritis/prostatitis(usually
  caused by infection)
• parasitic diseases (e.g. schistosomiasis)
• nephrolithiasis or bladder calculi
• Multiple sites or source unknown
• hypercalciuria
• hyperuricosuria

8

• System disorders
• a. Hematological disorders
• aplastic anemia leukemia
• allergic purpura hemophilia
• ITP (idiopathy thrombocytopenic purpura)
• b. Infection
• infective endocarditis
• septicemia
• epidemic hemorrhagic fever (Hantaan virus)
• scarlet fever (?-hemolytic streptococcus)
• leptospirosis (leptospire)
• filariasis (Wuchereria bancrofti, Brugia
  malayi)

9

• c. Connective tissue diseases
• systemic lupus erythematosus (SLE)
• polyarteritis nodosa
• d. Cariovascular diseases
• hypertensive nephropathy
• chronic heart failure
• renal artery sclerosis
• e. Endocrine and metabolism diseases
• gout
• diabetes mellitus

10

• Diseases of adjacent organs to urinary tract
• appendicitis salpingitis
• carcinoma of the rectum
• carcinoma of the colon
• uterocervical cancer
• Drug and chemical agents
• sulfanilamides anticogulation
• cyclophosphamide mannitol
• miscellaneous
• exercise idopathic hematuria

11
CLINICAL FEATURE

• Color
• depends on the amount of red blood cell in the
  urine and the pH (see slide 4)
• normal light yellow, pH 6.5
• pH
• acidic more darker (brown or black)
• alkaline red

12
DIFFERENTIAL DIAGNOSIS

• Polluted urine menstruation
• Drug and food phenosulfonphtha lein (PSP),uric
  acid, vegetable
• Porphyrism porphyrin in urine ()
• Hemoglobinuria
• hemolysis
• soy-like, very few RBC under the microscopy
• occult blood test ()

13
HEMOGLOBINURIA

• RBC abnormality
• Defects of RBC membrane structure and function
  (hereditary spherocytosis)
• Deficiency of enzymes (favism)
• Hemoglobinopathy (thalassemia)
• PNH
• Mechanical factor (artificial heart valve),
  infection
• or mismatched blood transfusion

14
LABORATORY TESTS

• Three-glass test
• Method collecting the three stages of urine of
• a patient during micturition
• Result
• the initial specimen containing RBCthe urethra
• the last specimen containing RBCthe bladder
• neck and trianglar area, posturethra
• all the specimens containing RBCupper urinary
• tract, bladder

15

• Phase-contrast microscopy
• to distinguish glomerular from post
  glomerular bleeding
• post glomerular bleeding normal size and shape
  of RBC
• glomerular bleeding dysmorphic RBC (acanthocyte)

16
EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST
(non-glomerlar)
RBC MCV 92.8 um3
17
(No Transcript)
18
(No Transcript)
19
EXAMPLE OF PHASE-CONTRAST MICROSCOPY TEST
(glomerlar)
20
(No Transcript)
21
(No Transcript)
22
ACCOMPANIED SYMPTOMS

• Hematuria with renal colic
• renal stone, ureter stone
• if with dysuria, miction pause or staining
  to void bladder or urethra stone
• Hematuria with urinary frequency,urgency and
  dysuria
• bladder or lower urinary tract (tuberculosis
  or tumor)
• if accompanied by high spiking fever, chill
  and loin pain pyelonephritis

23

• Hematuria with edema and hypertension
• glomerulonephritis
• hypertensive nephropathy
• Hematuria with mass in the kidney
• neoplasm
• hereditary polycystic kidney
• Hematuria with hemorrhage in skin and mucosa
• hematological disorders
• infectious diseases
• Hematuria with chyluria
• filariasis

24
--Approaching to the patient (Harrisons
Principle of Internal Medicine,14th Ed)
HEMATURIA
proteinuria (gt500mg/24h) Dysmorphic RBC or RBC
casts
(-)
()
()
Pyuria,WBC casts
urine culture eosinophils
serologic and hematologic evaluation blood
culture, anti-GBM Ab, ANCA, complement,
cryoglobulin HBV,HCV,VDRL,HIV, ASLO
(-)
Hb electrophoresis, urine cytology, UA of family
member, 24h urinary calcium/uric acid
As indicated retrograde pyelography or
arteriogram of cyst aspiration
(-)
()
IVP/-renal ultrasound
renal biopsy
(-)
()
cystoscopy
biopsy
(-)
ANCAantineutrophil cytoplasmic antibody,
VDRLvenereal dis. research laboratory, ASLO
antisteptolysin O, IVP intravenous pyelography
CT scan
()
open renal biopsy
(-)
follow